23270APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm'ed Identification
Building Address:
03
PERMIT NO.
2321n ^ f"� h% 0
e am
:?s-
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECIRICA nP SINGMECHAMCAL
A
�� q •�
/O�
con vier a Llc No:
Architect/En rrter. LIe No:
CATEGORY
CONTROLIf
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.
PERMTTI6 ANCE
❑ :1 11LICENSED
CONTRACTORS DECLARATION
Iherebya Jrm that l am licensed under pnovWoru of Chapter 9(mmmunc
ingwlth Sectbn7000)01 DMdon3ofthe BudneeandP fit or.Cade,and my
Iimnn iris , o ti teas .�
r
Da adA RA 4y
ARCHITE f
[ uriiennM my phv shel] be used as public reds
Limned Professional
OWNER -BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractor's License Law for the
following reason.(Sechon MIS, B.1iress and Prufmbv Code: My dty or
ntywhkhrequU aperr tomvtuMter,imp.,demolhh,ornpalr
any nsudurtpMto Its Lwnnsgrequires qubasthe.ppl]nntf¢suk
ctchpenmta
Ile . signed statement the he b licensed pursuant to the provbions of the
Contraors ldceme Law W) meencing with Section 70of Divi-
alno3 of the Budnesrnd Pmfembv Code) arthn he b e¢mpt therefromaM
the bash for the alleged e.emptlon. My violation of Section 70315 by any
applIcant fora permit subjects the. ppheant to a civil pevky d not mom than
!Wehundreddollenhe.
o sa owner of the ework.property, or my employees with ween r tier sok
InntnIWended oioften offered for
cumpask 5v- Hmi, wOldothBusinesand Professions
dole(Sec 7064,Bvinns.MPm!®bv Cade:The orCcunractoe.junp,,ea hence Law
don nonsuch torn awoerathrougproperty
iswho
who doesuch work e,not mselorthwghed ownemp, howevrwWed thatsud
own em orlmprovetknaRuch
an ea Intended
improvement one or arofee for sale. If, however, bulk ave
Improvement bead with in ovyerrafcamplabn,the wmn-0u11d<rwW have
t nienof pmving that he did rat build or improve for purpose of sale.).
Lj L u ams of the pmpenty, am erchuNely contracting with tins d
contract¢md
, to constthe pmjad I-.7014, BusloesaM Raesions Code,
The Contractor, License Law dm ma appy to an owner of property who
Wlw or Improve thceon, and who contracts for such piereca with r
Tacral licensed puwnt to the Contractors License Law.
TI am exempt under Sec B & P C for this ninon
APPLIANCE-RF_SIDENTIAL
JOBD N
r
PANELS
UP TO 2DO ANUS�//�yn
1-1000 AMPS
JOVER 10]0 AMPS
SQ. FT. FLOOR AREA S/SQ. FL.
D I N N
R
ad ��
SGNSU TRICAL Issal,,
SPECIAL CIRCUIT/MISE
T�p,MEM OR POLE INBI.
POWER DEVICES
EllgWIdAING POOL ELECTRIC
OUTLE MSWHOFQSHX UFES
AWA
NEW RESIDEtMAL ELECTR SQYT.
RIES
TYPE NNSI1il1CIlON
TOTAL
QTY. PLUMBING PERMIT FEE
PERMIT ISSIfANCE
ALTER-DRAIN&VENT - WATER (EA)
OCCGROUP
RES UNITS
FLODp 7DNE
APN
BAIX FLOW PROTECT DEVICE
FEE SUMMARY
DRAINS FLOOR, ROOF, AREA, GOND.
FO(7URES. PER TRAP
SANITARY Y_ N_
REOEI F #
Avner Dale
ORmthat COMP EN'SATION DECLARATION
jolTherby affirm that I have •lrcertificate of cones w Dpythe n, or .
¢nilioleof Workeri Comprndotlonlruur.n¢¢acertified ropylhenof 6ec.
3300, lab C)
��I A q�ereby ����e,��
SCHOOL TAX Y_ N_
RECEIPT If
GAS FA. SYSTEM -1 WC40UTLE15
PARK FEE Y N_
GAS- FA. SYSTEM -OVER 4(EA)
BUILDING IVISIO.N`FEES
CertNc3 copy b httedwththehed.
ropy b flied with the city, Ivpectbn divblon.
CERTIFICATE OF FXFMPHON FROM WORKERS'
COMPENSATIONotbecINSURANCE
(fhb section need not he compldd Permit the pedt b for one hundn
red dollars
15100 nifytJ
1¢ net emploin y penNtbbsuM,
artyhe pfo manynce annex week w as to which
1 shake not empen any person f any runner at u to become subject to the
wwlicni Compensation Laws ar California. Date
ApplhJOT[Cnt
you
shoulNONCE co APPLICANT:], akr ra' Co this ceiun pm a FiI of the I.abor
CompensationprovbbnsoftheatI
Code, become afornh to the ply with
Code, you nvne<forthwlth comply with each pnovlsbv arthb permit shall he
deemed revoked.-13UILDING
CONSTRUCTION LENDING AGENCY
I herebyetim"her'here Is, a contnmction lending agency for the perfonry
a of the work for which thb permit b issued (Sec 309'7, C1v. C.)
Lender's Name
lender. Mdness
I mdi"A I have rad tw appUutwnard date'hatthe above Infomntlon
bconeet I agree to comply withal] city.nd countymelinanm.nd rate laws
relating to building construction, and hereby authorise rtprnenlr'We of tw
city to enter upon the abwcmentbned property for bupedimn purposes.
(We) agree to saw, IndemNy an d keep harMem the City of Cu penal
.,abut BabWtle, P dements, m , and expense which may in any way. came
.Vint said Cly in covequeme of the granting of Mt this per
GREASE/INDUSfRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Rcoel LM
GREASE TRAP
SEWER-SANITARYSIORM EA. �7
WATER 11EATEn W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Reeel Ip
wATFIt sYSTFAI/1R[AnNG
NEH,REgpFNTLM PIMB. SQTT.
TOTAL:
FEE
TOTAL
5EISMIC FCF
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTER OR ADD TO MECFL
AIR HANDLING UNIT 8010,000 CFM)
DatC Reeei IM
SUBTOTAL_
AIR HANDLING UNIT (OVER 10,000 CEM)
CONSTRUCTION TAX
Slgrutun of Applicant/Contractor Date
HAZARDOUS MATERIALS DI SCIASURE
Will the a ppllca in or future bu llding occupant store or ha re le h.sardcan,
material as de0rad by the Cupertino Municipal Code, Chapter 9.1 7, and the
Flea tth.M Safety Code�37p)7
❑ Ye ..
Will the applicant¢ turc bu Ing «cupanl mea equipment¢ devim
which cent havrdous rir� rata as derby the Bay Ana Air
Qu.Wy Management DM
Yy
have read the Ease m.terlab mrylremenb under Chapter 6.95 of
the California Health& Safety Code, Sections 75505, 75533 755.x.1
u ndthat lithe bul]din does ret cu entyhavcate thatitbmy
Wtyton Ifythe pant th regWne I rruItbemet
,a,.. ace racy
IE4�lhorhced
EC IAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (M IW,= BTU)
Date RCCCI tin
HEATING UNIT (OVER 100,OOD BTL])
TOTAL:
VINHIATIONFAN (BINDLE REED)
ISSUANCE DATE
PAI b
WAR 31
IrY11 1992
CITY OF CUPEn i I9v
ISSUFDBY_
BOILER -NMP OMP OR l00,00o BTU)
BOfLER-COMP(OVER 100,OOD BTU)
NEW RESIDENTIAL MECH. SQ.FT
.gent pee
TOTAL
OFFICE COPY
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EiAG
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